HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 124 STONECLEAVE ROAD 8/26/2024 Commonwealth of Massachusetts t� LP� °vet
City/Town of
System Pumping Record
Forr1i 4
AUG , 202
DEP has provided this form for use by local Boards of Health, Other forms may be used;,.6�t 1h
information must be substantially the same as that provided here. Before using.thts form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
HOUSE: front Cack)side rear eft ight
A. Facility Information BUILDING: front back side rear left right
Important:when DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not K` N,nCQ��4/ MA
use the return Cil !Town
key. y State Zip Code
re
2. System Owner
Name
nhm
Address (if different from location)
MA
CltyRown Slate Zip Code
Telephonb Number
B. Pumping Record
1. Date of in Pum 2a 2 /�W
Pumping Date 2 Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank g El Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E ass 1AD31
Name Vehicle License Num er
Bateson Enterprises, Inc.
Company
7. ion where contents were disposed:
GLSD
lid Itj
Signature of Hauler Date
Signature of Receiving Facility(or•attach facility receipt) Date
15form4.doc• 11112 System Pumping Record •Page 1 of 1